Complete the entire form before submitting.
If you have any questions regarding the Right-to-Know form, Please contact the Mt. Pleasant Fire Department at 989-779-5105.
Form Completed by:
*
Date Completed:
*
-
Month
-
Day
Year
Date
This site is: (please check one)
*
Chemical User - (Chemicals used in activities on site)
Chemical Producer - (Chemicals manufactured at this site, includes packaging)
Other - Check this box if chemicals are stored on site, but not used or produced. Please Specify (Examples: service station, retail store, storage facility)
None – Do not store or have chemicals on site
Name of Premises
*
Site Address:
*
Site Property Tax ID (Found on letter you received):
*
City or Township:
*
Please Select
City of Mount Pleasant
Union Township
Site Telephone:
*
E-mail:
*
Emergency Contacts:
(Include Private Alarm/Security Companies)
Name:
*
Home Phone
Work Phone
Name:
Home Phone
Work Phone
Name:
Home Phone
Work Phone
Name:
Home Phone
Work Phone
Respond based on the maximum quantity you would have on-site, including storage, at any one time during the year.
Please select each drop down category and select one of the three choices for every chemical type.
Chemical Type Specified Quantity Select Specified Quantity for Each Category
Class 1
Explosives & Blasting Agents (Not including Class C Explosives)
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
Any Quantity
Class 2
Poison Gas
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
Any Quantity
Flammable Gas
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
100 gal. water
capacity
Non- Flammable Gas
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
100 gal.
water
capacity
Class 3
Flammable Liquid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
1,000 gallons
Combustible Liquid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
10,000 gallons
Class 4
Flammable Solid (Dangerous when wet)
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
100 lbs.
Flammable Solid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
500 lbs.
Spontaneously Combustible Material
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
100 lbs.
Class 5
Oxidizer
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
500 lbs.
Organic Peroxide
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
250 lbs.
Class 6
Poison
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
500 lbs.
Irritating Material: Liquid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
1,000 gallons
Irritating Material: Solid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
500 lbs.
Class 7
Radioactive Material (Yellow III Label)
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
Any Quantity
Class 8
Corrosive: Liquid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
1,000 gallons
Corrosive: Solid
*
Please Select
Do Not Have
Have at or Above Specified Quantity
Have but Below Specified Quantity
500 lbs.
No DOT Category
Known Human Carcinogen
*
Please Select
Do Not Have
Have
Any Category
Please submit form within 30 days of the official notification letter.
Comments:
Would you like to be contacted?
*
Please Select
Yes
No
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